Our Sensory world
See behaviour…think sensory
As well as bladder and bowel function, and development, it is often very useful to consider how sensations affect a child’s response to using the toilet.
When we think of how children understand their world, this includes understanding the impact of their sensory experiences. As they grow they experience a wider world, including nursery school, wearing pants and going to bathrooms. How they perceive and understand sensations may influence the strategies needed to help children learn to use the toilet. This can affect many children, and especially those with developmental difficulties or with autism.
We experience ourselves and the world around us through our senses. Most people have the ability to filter out a great deal of the sensory information they receive. Children often cannot do this so well, and can become easily overwhelmed.
We have emotional reactions to sensory experiences, and these may be influenced by memory and imagination as well as the physical sensations. There are some sensory experiences which we may love, such as the feel of being stroked, or looking at a flower, whereas there may be others which we dislike, such as the sound of fingernails on a chalkboard or a particular taste such as sprouts! We all appreciate sensory experiences differently, with often individual emotional reactions and memories.
Adjusting the sensory input can make a difference for many children to help them to learn toileting skills. As children grow they often learn to adapt and become comfortable to the sensations they experience.
This is received from our sensory organs and gives us information about our world. The sensory systems include: touch, balance, body position, vision, hearing, taste and smell.
Other sensory information is also received from our internal body organs including bowel and bladder awareness, which affects the ability to learn continence.
Our responses to sensory information may be affected by a range of factors; including our previous sensory experiences or how alert or stressed we are, and maturity.
Some children may be especially sensitive to the sensations they feel, and find them upsetting. They may perceive certain noises as unbearably loud, and touch may feel painful. This can lead to children avoiding sensory input they find upsetting.
This is where sensation may be reduced and the child doesn’t appear to register it. Some of these children may try to actively seek sensory input; these children often rock, spin or slap their hands to stimulate themselves with increased sensory sensation.
These different reactions can vary across the senses, meaning they crave input from one sense but actively avoid it in another.
Sensory aspects of toileting
Toileting, like eating, is an extremely sensory experience. Many children find that bathrooms and toilets are upsetting or scary.
They may have difficulties in understanding the sensations experienced by their own body, and knowing how to react to them.
It is useful to look at the different sensory experiences a child has and try to analyse and understand which aspects are causing difficulty. This helps in appreciating a child’s perception and difficulties, and to create an environment where the child feels more relaxed, secure and comfortable.
Touch provides information about the sensations we feel on our skin and about the objects and textures we come into contact with. Children will feel surfaces as hard or soft, hot or cold, rough or smooth. The hands and genitals have high numbers of touch receptors, so are especially sensitive.
Children who are sensitive to touch may not like sitting on toilet seats, which may feel hard or cold. They could be upset by feeling wee or poo on their hands or body, and feeling splashes of water from the toilet. They may not like the sensation of toilet paper or wipes, solid or liquid soaps. Touch and contact with bathroom furniture and flooring may also affect them.
Children who have reduced sensation may not notice when they are wet or soiled, and may enjoy the extra tactile experience from playing with their poo. They may like the feeling of wee and poo in their pants or nappy, or the contact provided by wearing a nappy. They may like exploring the sensations gained from playing with bathroom products.
The balance system gives information about movement and where our body is in space.
Children who are upset by balance sensations may feel unsteady on the toilet, particularly if their feet can’t reach the floor. The memory of previous experiences of feeling unstable can continue to affect their confidence. Some children may find an open space or gap at the side of the toilet affects their position sense, and they may feel more secure in toilet cubicles with walls on either side. The reflections from tiling or mirrors or changes in floor surfaces may make them feel unsteady.
Children who have reduced sensation or sensory seekers may feel a need to rock to stimulate their balance system, and find it difficult to sit still on the toilet.
Body awareness (Proprioception):
This sensation tells us where our body is in relation to the world around us, helping us know which parts of our body are moving and allowing us to control movements without looking. It also gives information about the pressure needed to manipulate objects.
Children who have increased awareness may have more sensation from sitting on the toilet, and they may be aware of the contrast of the hard toilet seat and the space inside. They may find these feelings uncomfortable or even painful.
Children who have reduced sensation seek increased stimulation and may enjoy the deep pressure they get from wearing a nappy. Nappies and tight clothing may increase the awareness of their body position and help coordinating movement. They may be unsure of their position on the toilet, or where to put their feet. Some children may try to feel their body better by pushing themselves back to feel the toilet cistern behind them.
Children often find wiping themselves difficult. This can be linked with difficulties in coordinating their movements and using the right amount of pressure to clean themselves.
Sight provides information about objects and people around us, enabling us to define the boundaries of things we can see.
Children who have increased awareness of visual stimulation or sensory avoiders may struggle with the confusing amount of visual input in a bathroom. This can come from bright lights, reflections from tiling, mirrors, windows and bathroom fitments. They may be overwhelmed by the range of colourful toiletry products, towels or patterned flooring. This visual input may be distracting and sometimes cause anxiety and distress.
Children who have reduced awareness or sensory seekers may struggle with distinguishing what it is they are supposed to be focusing on in the bathroom, or may be actively seeking reflections or bright lighting.
Hearing provides information about whether sounds around us are loud, soft, high, low, near or far.
Children who are very sensitive to sound may struggle with the variety and volume of sounds within a bathroom. These include echoes, running water, flushing toilets, fans, etc. Some children may find the sound of wee or poo landing in the toilet worrying. Hand-dryers can be particularly difficult for many children, and can feel like a loud and painful sound. Toilets and bathrooms are often echoing places, especially in larger school and public toilets.
Children who have reduced sensation or are sensory seekers may be unaware of or actively seek out some of the sounds within the bathroom. They may enjoy the sound of the toilet flush, and they may want to play with this rather than using the toilet. Some may enjoy the noises that may echo in a bathroom.
Taste and smell:
This provides information about different types and varieties of smell; many of which are present in different bathroom products. The experience of smell is often an emotional experience and very individual.
A child who very sensitive may find certain smells unpleasant or distressing. These smells could include wee and poo, their own or other people’s. There are often strong perfumes in toiletries and cleaning products and these can be overwhelming, especially in a small bathroom.
Children who have reduced sensation or sensory seekers may not notice the smell of wee or poo if they are wet or soiled. Some may actively seek out strong smells, and sniff or play with bathroom products. They might enjoy the smell of poo, and may explore this by smearing poo.
Body signals (Interoception):
There are receptors located throughout the inside of our body, which gather information from the body and send it to the brain. Our brain helps to make sense of these messages, and enables us to feel things such as a full bowel or bladder or if we are hungry or thirsty.
Many children may not notice these sensations, or may miss them completely. For some children, who get the sensations sometimes, they are more likely to be unaware of them if they are tired or getting sensory input from another source, such as a computer game, which can distract their attention.
The bowel and bladder are smooth muscles, and the sensory signals they send to the brain are like soft whispers in comparison to messages from other parts of the body.
Some children may seek increased sensation from their body, and gain a positive reaction to the feeling of a full bowel or bladder. Interoception is also linked to feeling our emotions.
How to help children with sensory needs:
- It helps to understand a child’s individual needs and create the right environment for them. Children often have different sensory needs, and it is helpful to explore a child’s reactions to the different sensations they experience.
- Consider ways to reduce a child’s anxiety and help them to feel relaxed. Use distraction, stories, music, and a special toy.
- Look at the environment and reduce stimulation the child finds upsetting.
- If children need increased stimulation look at ways of providing this, or give alternatives.
- Many children may benefit from a mixture of sensory inputs scheduled into their day.
How to adjust sensory input
Reactions to sensation can be affected by stress, previous memories and experience.
It can be helpful to build a scheduled mixture of sensory inputs into a child’s daily routine. The aim of this is to help their nervous system feel better organised, and support with attention and performance through providing a mixture of calming, alerting and organising activities.
This is helped by activities to relax the nervous system, and reduce anxiety and sensory overload.
Examples include stress balls or fiddle toys, weighted mats, rocking chair, soothing smells, low level lighting, relaxing music, sleeping bags, blankets or cushions or deep pressure massage, and calming music.
Activities to help with alerting the nervous system, with the aim of helping the child become more focused and attentive.
Examples include bright lighting, loud music, strong smells, messy play, running games, ball bouncing, trampoline or alerting sensory toys.
Ways to alter sensory inputs:
Tactile, balance and body position
- Consider if the toilet seat is right, and if necessary experiment with an alternative shape or cover that gives a different tactile feeling. A padded seat may feel softer and warmer.
- Consider the texture of toilet rolls or wipes and work out which the child is happy with.
- Consider the temperature of the bathroom and how this might affect the toilet seat, floor and environment.
- Provide toys and activities which offer extra tactile input if needed.
- Build in more opportunity for movement activities, including bouncing on therapy balls, wheelbarrow walks, doing push-ups against walls or things that the child can fiddle with.
- Consider increased experiences at other times to give more opportunity for movement, such as wobble cushions, beanbags.
Limited awareness of wee or poo in nappy or pants
- Use a nappy liner pad/folded kitchen paper or pants worn inside the nappy to increase awareness of wetness
Limited awareness of body sensations – ‘not feeling the need to go’
- Use visual reminders, timers, phone alarms or a vibrating watch as an indicator to go to the toilet
- For some children, letting them go without pants in the summer so they can see and feel when they have done a wee, and learn to connect this sensation with themselves
Positioning on the toilet and feeling secure
- Use a foot stool (this is always a good idea!)
- Use a toilet seat with a smaller hole, such as a children’s toilet seat insert
- Install a handrail, both sides if needed
- Have feet marks on the floor or stool to show where the feet should go to help correct positioning
- Use a lap-pad to increase body awareness (can help increase sensation from their legs through the pressure that’s provided)
- Use a rolled-up towel or a cut up foam swim tube behind them, to show them how far back they should sit, increase awareness and provide a feeling of security
- Allow the child to squat on the toilet if that is the best position for them
- Use a device that allows them to squat e.g. Squatty Potty
Flooring – impact on balance, vision or temperature
- Cover tiled or patterned flooring with a non-slip mat
- Avoid having too many changes or varieties in colour or texture
Anxiety about wee or poo touching or splashing on their body or clothes
- Put a piece of toilet paper in the toilet before using it to reduce risk of splashes
- Teach the child how far down to pull their trousers, pants or skirt
- Child wearing disposable gloves to avoid contact with wee or poo
- Using wet wipes for cleaning themselves (remember – most are not flushable!)
Wanting the sensation of wee or poo in nappy or pants as this gives increased tactile experience
- Explore options to increase tactile sensory input in other ways, for example tightly fitting clothing or fiddle toys
Wanting the sensation of wearing a nappy – as it may be providing deep pressure
- Allow the child to wear tight fitting pants, leggings or shorts, for some children you may need to do this over the nappy initially
- Provide deep pressure in other ways – using weighted lap-pads or blankets, massage or tight clothing
- Gradually reduce the tightness of the nappy as the child gets more confident
It is often important to try and create a low arousal environment so the child feels more safe and secure.
For those upset by too much visual input:
- Reduce the amount of visual information on the walls, and think about the need for calming colours for walls and towels
- Reduce glare from lighting – small press-on lights or low wattage bulbs may be useful
- Think about reflections, and whether mirrors need to be changed, covered or removed
- Some children may wear sunglasses to reduce visual input and these may be useful in the bathroom
- Reduce visual overload by putting toiletries or equipment in boxes or out of direct line of vision
For those needing increased visual input:
- Bright lighting may be needed
- Provide visually stimulating input for the child to see, such as charts, pictures, cartoons, sensory lights or ceiling mounted fiddle toys or mobiles!
The sound of the hand-dryer petrified him…until we realised that he never knew that it actually stopped ….explaining how it worked helped him understand and manage his fear – he then wanted to stay and count how long it lasted before stopping!
For those upset by too much noise:
- Use ear-defenders, earplugs or headphones for accessing some bathrooms, particularly public toilets
- Use curtains, mats or towels to reduce the impact of echoes in the bathroom
- Putting a piece of toilet paper in the toilet prior to using it can decrease the sounds that weeing or pooing can make
- Avoid or reduce the use of hand-dryers
- If a child finds flushing distressing, try recording the sound of the flush, and using this to gradually desensitise them
- For those who need increased sound input: Provide alternative things to provide auditory input if this is what the child is seeking, for example musical or other toys with interesting sounds
- For repetitive flushing, include a visual cue for a single flush followed by a different enjoyable activity
For those who are upset by smells:
- Reduce smell input by using non-perfumed toiletries and cleaning products, and consider detergents used on towels
- Use odour neutralisers
- Install an extractor device and ensure good ventilation
- Allow a child to take something they like with them to sniff to distract from other smells
For those wanting to experience and explore smells:
- Increase smell input by using air-fresheners
- Allow a child to have something with them to sniff to provide them with strong olfactory input, by using a wristband with perfume or essential oil or scratch-and-sniff stickers
- Build in experience of olfactory stimulation in their daytime routine